Basic Information
| Provider Information | |||||||||
| NPI: | 1811161425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE PRIMARY CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 1 RIDGEWAY | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135859009 | ||||||||
| FaxNumber: | 5135859373 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 THOMAS MORE PKWY | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594261800 | ||||||||
| FaxNumber: | 8594264828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 04/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 5135859336 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2178165 | 05 | OH | MEDICAID |